Challenges of an Outcome-Based Perspective for Marriage and Family Therapy Education THORANA S. NELSON, PH.D.w SARA A. SMOCK, M.S.z Marriage and family therapy (MFT) and marriage and family therapy education (MFTE) have undergone many changes during the short history of MFT. This article describes the current trends and controversies in MFTE, including shifts toward outcome-based education (OBE). We present recommendations for MFTE, including the move toward OBE, the development of core competencies of MFT, attention to interdisciplinary issues, and recognition of the need for both foundational education and encouragement of trainees’ unique styles and approaches. Fam Proc 44:355–362, 2005 O ver time, the practical nature of marriage and family therapy (MFT) has changed in terms of models, modalities, emphases, and, for some, philosophy of science. The field has developed widely disparate models of therapy ranging from prescriptive and formulaic sets of interventions to postmodern philosophies that view change as ‘‘emerging’’ through ‘‘conversation.’’ The plethora of approaches has led to a dilemma in marriage and family therapy education (MFTE): Should we be a specialty and a distinct discipline with circumscribed boundaries of theory and practice, or should we remain multidisciplinary and broadly defined so that we more easily fit into the mainstream of mental health? Rather than resolve the dilemma, standards for education have attempted to do both: require clear foundational elements, and at the same time, maintain flexibility for individual programs to train students in their own philosophies and styles. This article describes influences on MFT and MFTE and describes a new paradigm for educating MFTs: outcome-based education (OBE). wUtah State University. zVirginia Polytechnic Institute and State University. Correspondence concerning this article should be addressed to Thorana S. Nelson, Ph.D., Professor, Department of Family, Consumer, and Human Development, Utah State University, 2700 Old Main Hill, Logan, UT 84322-2700. E-mail: Thorana.nelson@usu.edu The authors would like to thank Todd Graves for his assistance in preparing this article. 355 Family Process, Vol. 44, No. 3, 2005 r FPI, Inc. 356 / FAMILY PROCESS INFLUENCES ON MFTAND MFTE Social Influences Social movements have contributed to the nature of MFT and MFTE. The radical ideas of the 1960s and 1970s gave rise to the ‘‘brief therapy’’ of the Mental Research Institute (Watzlawick, Weakland, & Fisch, 1974), with fundamental changes in how therapy was conducted and how therapists were trained. Similarly, the civil rights and women’s movements led attention to an examination of socialization practices and therapy that are disadvantageous to women (Hare-Mustin, 1978) and minorities. As persons of influence through our educational privilege, we began to take seriously our own systemic positions as advocates not just for families, but also for justice. This sensitivity to differences and diversity led to added requirements in MFTE around these issues. MFT Practice The changing nature of the practice of MFT, including increased focus on medical models and managed care, required that programs help students learn the language of mental health, not just the ‘‘purist’’ language of systems. Increased empirical evidence that family therapy is helpful to a variety of clinical concerns (Sprenkle, 2002) required attention in MFTE to evidence-based therapies and the practices that lead to successful therapy. Managed care has increasingly focused on these models of therapy and on the responsibility of therapists to demonstrate that what they do with clients actually produces positive therapeutic outcomes. Outcome-Based Education Gradually, without much notice, the call to accountability in practice has given rise to a shift in educational principles. Moving from an input-based philosophy, one in which educational institutions and programs must teach certain things, we are faced with outcome-based education (Manno, 1994). An outcomes base requires understanding that just because we provide students with a variety of educational material doesn’t mean that they will actually learn the material. Rather, education is shifting from a perspective of what is taught to one of what is learned. Educational units (elementary and secondary schools, university programs and departments, and colleges) are charged with demonstrating that students who graduate from their programs actually have learned something regardless of what and how many courses or tests they have passed; we must show that students are competent in their fields of study. Although an outcome-based approach to education seems ideal, controversy exists concerning its usage. First, it will require a modification of educational philosophy and an investment in both time and money for educators (Manno, 1995). Next, the nature of the outcomes themselves presents difficulties. According to Solway (1999), syllabi will be dictated by outcomes defined by outsiders rather than educators. In this argument, the voices of educators will be overridden by the dominant values of those who define the outcomes. This means that education may become or appear to become more an issue of political gain than competency training. Manno suggests that this can be avoided by presenting many options for training. In MFT education, this is likely to mean that our diverse training programs will remain popular and strong. In addition, www.FamilyProcess.org NELSON & SMOCK / 357 many of the outcomes themselves, in the form of core competencies (CC) developed by the American Association for Marriage and Family Therapy (AAMFT; described later in this article), have been defined by educators. The main criticism of OBE lies in the difficulty of finding outcomes that are clearly specified and valid and that can be measured accurately. Many outcome variables are vague and include values and beliefs, not solely academic achievement (Manno), which leads to ineffective applications of OBE. Despite the concerns of implementing OBE, there are several advantages of such an approach. Those in favor of OBE suggest several advantages (Willis & Kissane, 1997). First, a clear and universal method of evaluation will aid in student achievement. Next, OBE is seen as possessing the ability to ensure that all students will succeed with quality outcomes. Together, these advantages suggest that standardized outcomes and assessments will lead to uniformity and to consistently trained, competent therapists. The third strength of OBE is that accountability for educators will rest upon student performance rather than institutional resources. The OBE movement is prevalent in higher education all over the United States. Finally, OBE is likely the best way to help students be active in their own learning processes and to connect skills, abilities, and competencies with real-world situations (Spady, 1994), something that MFT training focuses on by coupling didactic coursework with clinical experience and supervision. Similarly, MFT programs that help their students to think about what they think in terms of theory and change (Nelson & Prior, 2003) may be assisting their students by encouraging them to make connections between theory and skill rather than focusing on each independent of the other. Thus, in many ways, MFTE programs are already using OBE principles. Accreditation Standards The shift to OBE affects marriage and family therapy education, as well as education in other fields. The standards for accreditation of family therapy programs are currently undergoing a cyclical review by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) and are moving in the direction of outcome-based education. That is, in addition to demonstrating that a program can provide a structure and context conducive to learning, input-driven standards (a certain number and kind of courses and a certain number of hours of clinical experience supervised in a particular way) will likely fade except as guidelines for teaching strategies. Standards that replace them may require that students be able to articulate an understanding of family therapy concepts and models of therapy, or that they demonstrate certain competencies that are pertinent to the general practice of mental health, and specifically, family therapy. Core Competencies The AAMFT is in the process of defining such competencies. A task force commissioned by the Executive Director of the AAMFT has developed a list of critical skills that family therapists should possess in order to practice therapy independently or to obtain licensure in MFT.1 As a step toward defining MFT in terms of what we do 1 The reader is directed to the AAMFT’s Web site (http://www.aamft.org) for a review of the list of core competencies. Fam. Proc., Vol. 44, September, 2005 358 / FAMILY PROCESS in addition to what we believe, the list has been received well and its development continues. A group of MFT programs is developing products to assist in this transition, particularly assessment and teaching tools. In addition, the CC list will become part of the guidelines for the revised accrediting standards of the COAMFTE and for those who supervise postgraduate trainees. RECOMMENDATIONS In 1988, Keller, Huber, and Hardy called for the field of marriage and family therapy to address the need to balance the integrity of the field through specific and high standards that are achievable to those who desire an identity and career in MFT. That is, we want to be an exclusive club, but not too exclusive. Trainees must be competent as general mental health professionals and as relational therapists. Therefore, we must demonstrate that family therapists are competent in a variety of areas, including mental health diagnosis, cultural sensitivity, ability to collaborate with a variety of professionals, and technical skill in working with individuals, couples, and families. The AAMFT core competencies may help us to assess these skills. For many years, MFTs were trained primarily in other disciplines and received their MFT educations after obtaining a degree in a different mental health discipline. As more programs have become accredited by the COAMFTE, more young professionals are trained and licensed exclusively as MFTs. These professionals do not have the luxury of relying on other degrees or licenses for legitimacy or reimbursement. This requires a critical mass of identified MFTs to maintain licensure and policies that are MFT-friendly, such as inclusion in federal policies and programs, reimbursement through third-party payers, and greater viability alongside other mental health professionals as equals. We need to be thoughtful about educational requirements for both those who desire an identity and training primarily in MFT, and those with primary training in other fields, such as social work, counseling, and psychology. The question remains, however: How much and what kind of family therapy training is necessary? Many therapists trained or training primarily in MFT claim that a course or two is insufficient and that supervision must be done by systems-trained MFTs. Others, preferring to avoid narrowly defined courses of study (input-based standards), would be pleased to welcome all professionals who are systemic regardless of primary identity. This would allow for both a primary identity as an MFT and recognition that family therapy and family therapy training occur and will continue to occur within other disciplines (see other articles in this issue of Family Process). To the extent that all who educate and train MFTs continue to discuss issues such as who we are and what we do, the field will reflect the diversity and experiences of many professions. At the same time that we strive to maintain identity as family therapists, we are faced with models of therapy that are not always clearly identifiable as systemic (e.g., solution-oriented and narrative approaches), as well as models that integrate psychological, medical, and relational concepts. This presents special challenges to practices in family therapy education, including the need to limit coursework and other requirements in master’s degree programs so that they are reasonable in both length and cost, as well as adequate for training new professionals. Programs will find their own ways to balance these issues. In light of changes in definitions of family www.FamilyProcess.org NELSON & SMOCK / 359 therapy and the need to adjust educational practices, we present several recommendations and ideas for consideration. OBE Focus Hoge, Huey, and O’Connell (2003) point us in the direction of graduate educational reform and improvements. These include best practices of methods in teaching, content, sites of training, and student and faculty characteristics. We know very little about these from an empirical standpoint and need to both learn from other fields of education and develop our own unique policies, procedures, and curriculum. OBE best practices require that we pay attention to the knowledge, decision-making skills, performance, and personal attributes of entering students and graduates. Outcomebased education assesses what students have learned and how they can use this learning in solving real-world problems. This is critical in marriage and family therapy and in other mental health professions. To date, however, educational practices have not been based on research, which suggests that we have much to learn about the best best practices for our field. Stuart, Hoge, and Tondora (2004), leaders in the movement of outcome-based education, suggest that we approach graduate education from an adult learning perspective. That is, education and teaching should be based on a perspective that learners construct knowledge in a context of problem solving. In addition, learners are at different stages of readiness for learning different aspects of professional knowledge and practice. Therefore, we suggest that programs focus more on student learning needs than curriculum and other input requirements, using practices that demonstrate the best student outcomes. This can be accomplished in part through a process of seeking feedback from students, assessing their outcomes against evolving standards of competency, and modifying programs accordingly. These changes in focus parallel changes in both education and the practice and profession of family therapy and will allow for the flexibility needed to accommodate the changes that our field and society are experiencing. Competency Focus We also suggest that student learning focus on outcomes of competencies or skills. The AAMFT core competencies is a good step in this direction, and we welcome the evolution of this concept and list. Competencies in terms of skills alone are not sufficient, however. It seems to us that basic knowledge of the history of the field, foundations of philosophy of science and systems thinking, and basic understanding of the variety of approaches, perspectives, models, and modalities for conducting therapy also are needed. Without a deep understanding of basic mental health concepts and family therapy constructs, it seems that informed integration of theory and competent practice would elude even the most gifted therapist. At this time, we recommend no substantive changes in curriculum. However, we do suggest that programs strive to remain current with mental health developments and include opportunities in their curricula for students to learn about these developments. We suggest that programs be given flexibility for training in both breadth and depth of theory and approaches while we make the transitions required by OBE. Fam. Proc., Vol. 44, September, 2005 360 / FAMILY PROCESS Foundations We also believe that family therapy education should continue to include foundational material in human and family development across the lifespan. It is important for family therapists to have knowledge of basic ideas of life cycle constructs, developmental theory, and interactional theory. It is particularly important that family and human development be recognized in the context of diversity of family forms, cultural sensitivity, and power and privilege related to race, economics, sexual orientation, and gender. We believe that educating students about human and family development across the lifespan is a deficiency in MFT. Students learn a great deal about clinical skills, theoretical approaches, and research methods, but very little in this area in some programs. Similarly, as we have developed our identity as a specialty in MFT, we have included less information about personality and psychology, counseling theory, and medical models of mental health practice. Much of this has been deliberate because of our perspective of the location of problems in contexts and relationships rather than as only psychological. Over time, however, many practitioners have integrated these factors into systemic thinking and constructed knowledge. Inclusion of all these areas in MFT education would lead to prohibitively extensive and expensive requirements, and we are not suggesting increases in MFT educational standards along these lines. Rather, we are suggesting that students become more clearly informed of the richness of interdisciplinary training and the need for information in these areas, both as prerequisites for master’s education and for postgraduate training. We further recommend that MFT doctoral education focus primarily on teaching, research, and specific content areas of practice and not become the entry degree for the practice of marriage and family therapy. MFTs with doctoral degrees should not be perceived as better clinicians than those with master’s degrees. Both levels of education should include more interdisciplinary training. It is important for family therapists, who will continue to be providers in the mental health delivery system and the diagnostic models that drive it, to be knowledgeable about those systems and the political forces that drive them. Evaluating Education Hoge et al. (2003) suggest that the content of education be routinely updated, focus on skill development, and instill in students an understanding of the competing paradigms of the field of study. In addition, Hoge et al. suggest that content prepare students for their political contexts in terms of science, the profession, economics, and social forces that shape health care and affect families. Ham (2001) challenges us to ‘‘broaden the space’’ in which family therapy learning, teaching, and training intersect, using societal change as an opportunity for a collaborative approach to learning. These changes in content and context also will accommodate the changes that are occurring in society. We recommend attention to them and to continually evaluating and updating educational practices and definitions of outcome. Teaching Methods Hoge et al. (2003) suggest that we employ best practices of teaching methods. These include a competency-based perspective and the notion that students should be taught lifelong learning skills and that teaching methods should be evidence based. At this www.FamilyProcess.org NELSON & SMOCK / 361 time, we have no research on outcome-based education in family therapy and very little collectively in education. This will require that programs continually evaluate, revise, and reevaluate their curriculum, teaching practices, and assessment strategies. Just as we are increasingly becoming an evidence-based profession, we must become evidence-based in our educational content and practices. The AAMFT’s efforts to define competencies and ways to teach and assess them moves us in this direction, and we encourage continued efforts toward these goals. Self-Awareness An outcome that we value is students’ ability to articulate their own theories of change and how change occurs in therapy (Nelson & Prior, 2003). By stepping back and looking at what they believe they believe, what they think they know, and how they think they intervene as family therapists, students possess a greater ability to critically integrate new material and to evaluate their practices. In effect, this makes them mini-researchers, continually examining their practices for effectiveness and revising them in mindful ways. Beginning to develop this skill early in graduate education and continuing it throughout the student’s program will contribute to students’ abilities to be self-aware and lifelong learners. Some may think that OBE will turn MFT graduate programs into cookie cutters. We believe that the best way to prevent this, and for students to learn their own strengths and the skills necessary to be good therapists, requires that they learn to be critical thinkers and consumers of education. This will lead naturally to individualized competency and knowledge. Social Issues We recommend that family therapists continue to use unique perspectives of understanding systems dynamics to examine social issues. Although AAMFT has not yet elected to take positions in social debates such as reproductive choice, same-sex marriage, or the dynamics of war, AFTA has done so, along with individual practitioners. We believe that students should be exposed to these debates and encouraged to examine the factors for themselves, using critical thinking, problem-solving skills, and a value base of healthy relationships. In this way, therapists will be mindful of social change, our part in it, and our responses to it. Collaboration Similarly, family therapy students must learn collaborative perspectives and skills so that they can work with other systems and professionals that impact clients’ lives. This can be done through training with interdisciplinary teams and lectures, seminars, and brown bag presentations by practitioners in different disciplines such as psychiatry, pharmacy, medicine, and corrections. Although we may disdain medical models and language, we are in an advantageous position of being able to interact with and influence other professionals and systems because of our understanding of systems and interactional dynamics. This is particularly important as family therapy broadens practice into larger systems that impact our clients and our profession. Fam. Proc., Vol. 44, September, 2005 362 / FAMILY PROCESS CONCLUSION We have led the reader in an article describing trends in family therapy education practices and recommendations for future modifications. We call for a paradigm shift in family therapy education, one that moves from input-driven to outcome-based educational practices, focusing on the student as an active learner who must develop a base of competencies to practice effectively and ethically. At issue is the identity of the field as a separate discipline or as a subspecialty of other disciplines, and of ourselves as mental health generalists or relational specialists. In true systems fashion, we believe that we are differentiated within the broader mental health field and that our particular way of working allows a relational perspective of mental health and therapy. Family therapy education also can maintain high yet attainable standards that make us leaders in the training of mental health professionals. REFERENCES Ham, M.D. (2001). Broadening the space of family education and training: Opportunities for transformation. Journal of Systemic Therapies, 20, 24–35. Hare-Mustin, R. (1978). A feminist approach to family therapy. Family Process, 17, 181–194. Hoge, M.A., Huey, L.Y., & O’Connell, M.J. (2003). Best practices in behavioral health workforce education and training. Retrieved July 7, 2004, from http://www.annapoliscoalition.org/pdfs/ best_practices_manuscript.pdf Keller, J.F, Huber, J.R., & Hardy, K.V. (1988). Accreditation: What constitutes appropriate marriage and family therapy education? Journal of Marital and Family Therapy, 14, 297–305. Manno, B.V. (1994). Outcome-based education: Has it become more affliction than cure? (Report– Evaluative/Feasibility No. 142). Minneapolis, MN: Center of the American Experiment Report. Manno, B. (1995). Educational outcomes do matter. Public Interest, 119, 19–27. Nelson, T.S., & Prior, D. (2003). Theory of change projects in marriage and family therapy programs. Journal of Contemporary Family Therapy, 25, 133–151. Northey, W.F., Nelson, T.S., & Chenail, R.J. (forthcoming). The development of the core competencies for the practice of marriage and family therapy. Solway, D. (1999). Reference seven. Outcomes based education: A referential tragedy. International Journal of Applied Semiotics, 1, 57–66. Spady, W.G. (1994). Choosing outcomes of significance. Educational Leadership, 51, 18–22. Sprenkle, D. (2002). Effectiveness research in marriage and family therapy. Alexandria, VA: AAMFT. Stuart, G.W., Hoge, M.A., & Tondora, J. (2004). Theory and evidence-based teaching strategies: Implications for behavioral health. Retrieved July 7, 2004, from http://www.annapoliscoalition.org/pdfs/Teaching_Strategies_2-20-04.pdf Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: Norton. Willis, S., & Kissane, B. (1997). Systemic approaches to articulating and monitoring student outcomes: Are they consistent with outcome-based education? Studies in Educational Evaluation, 23, 5–30. www.FamilyProcess.org